Provider Demographics
NPI:1316209620
Name:GOTSIRIDZE, GEORGE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:GOTSIRIDZE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12919 ALTON SQ APT #209
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:781-249-2087
Mailing Address - Fax:
Practice Address - Street 1:12919 ALTON SQ APT #209
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170
Practice Address - Country:US
Practice Address - Phone:781-249-2087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014136211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice